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In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?
- A. Measure the client's oxygen saturation before taking further action
- B. Administer a PRN dose of nitroglycerin (Nitrostat)
- C. Administer the dose of furosemide as scheduled
- D. Hold the dose of furosemide until contacting the healthcare provider
Correct Answer: D
Rationale: Elevated BNP levels in a client with heart failure may indicate worsening heart failure. Therefore, the correct action for the nurse to take when encountering an elevated BNP before administering furosemide is to hold the dose and contact the healthcare provider for further guidance. This precaution is necessary to ensure the client's safety and prevent potential complications. Options A and B are incorrect as they do not address the issue of the elevated BNP, which is crucial in this situation. Option C is also incorrect because administering furosemide without consulting the healthcare provider could be harmful if the client's condition is deteriorating.
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The nurse is assessing a first-day postpartum client. Which finding is most indicative of a postpartum infection?
- A. Oral temperature of 100.2°F (37.9°C)
- B. Blood pressure of 122/74 mmHg
- C. Moderate amount of foul-smelling lochia
- D. White blood count of 19,000/mm³ (19x10^9/L SI units)
Correct Answer: C
Rationale: A foul-smelling lochia is indicative of a postpartum infection, such as endometritis. Foul-smelling lochia suggests the presence of infection due to the breakdown of tissue by bacteria, leading to the malodor. An oral temperature elevation and an elevated white blood cell count are nonspecific and can be present in various conditions other than postpartum infections, making them less indicative. A blood pressure within normal limits is not typically associated with postpartum infections.
A new mother asks the nurse if the newborn infant has an infection because the healthcare provider prescribed a blood test called the TORCH screen test. Which response should the nurse offer to the mother's inquiry?
- A. Rising titers identify the etiology of certain neuro-sensory birth defects
- B. The screen determines the risk for inherited anomalies in the newborn
- C. The test identifies the correct antibiotic to give the newborn for an infection
- D. Exposure to infections that can cross the placenta cause a positive antibody titer
Correct Answer: D
Rationale: The TORCH screen test is used to detect infections that can affect the newborn by showing if there was exposure to these infections. Choice A is incorrect because the TORCH screen test is not specifically for identifying the etiology of neuro-sensory birth defects. Choice B is incorrect because the test does not determine the risk for inherited anomalies. Choice C is incorrect because the test is not used to identify the correct antibiotic for an infection, but rather to detect infections that may have affected the newborn.
The client with diabetes mellitus type 1 has a fruity breath odor. What is the priority nursing action?
- A. Evaluate the client's intake and output
- B. Measure the client's capillary blood glucose
- C. Consult with the dietitian about the client's diet
- D. Apply a pulse oximeter to the client's finger
Correct Answer: B
Rationale: Fruity breath odor in a client with diabetes mellitus type 1 can indicate ketoacidosis, a serious complication. Measuring the client's capillary blood glucose is the priority nursing action in this scenario as it helps diagnose and manage the condition effectively. Evaluating intake and output may be important for overall assessment but not the priority when dealing with a potential emergency like ketoacidosis. Consulting with a dietitian about the client's diet is important for long-term management but not the immediate priority. Applying a pulse oximeter is not relevant to addressing the fruity breath odor and suspected ketoacidosis.
After 2 days of treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child's urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement?
- A. Perform a finger stick glucose test
- B. Increase the IV fluid flow rate
- C. Review 24-hour intake and output
- D. Obtain arterial blood gases
Correct Answer: A
Rationale: Lethargy and difficulty arousing may indicate hypoglycemia, which should be assessed before other actions. Performing a finger stick glucose test is crucial to evaluate the child's blood sugar levels and address hypoglycemia promptly. Increasing the IV fluid flow rate is not indicated without knowing the glucose status. Reviewing 24-hour intake and output is important but not the priority when lethargy and difficulty arousing are present. Obtaining arterial blood gases is not the primary assessment needed in this situation.
An adult male is admitted to the intensive care unit because he experienced a sudden onset of sharp chest pain and shortness of breath earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with a pulmonary embolism. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor signs of increased bleeding
- B. Instruct on the use of incentive spirometry
- C. Observe for confusion and restlessness
- D. Administer intravenous opioids for severe pain
Correct Answer: A
Rationale: In a patient diagnosed with a pulmonary embolism, the most critical intervention is to monitor for signs of increased bleeding. Pulmonary embolism treatment often involves anticoagulation therapy, which increases the risk of bleeding. Monitoring for signs of bleeding such as bruising, petechiae, hematuria, or gastrointestinal bleeding is essential to prevent complications. Instructing on the use of incentive spirometry can be beneficial for preventing pulmonary complications but is not as urgent as monitoring for bleeding. Observing for confusion and restlessness may indicate hypoxia but is not the most crucial intervention in this scenario. Administering intravenous opioids for severe pain might be necessary but is not the priority compared to monitoring for bleeding, which is directly related to the treatment for pulmonary embolism.